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MEDICAL PLAN COMPARISON CHART – 2007
All benefits for the nonparticipating providers in the Preferred Provider Plan are payable after the application of the annual deductible, unless otherwise noted. All plan benefits shown as a percent relate to a percentage of the eligible charge. The eligible charge is the amount that HMSA’s participating providers have agreed to accept as payment in full for services rendered. Services received from a nonparticipating provider will likely result in significantly higher out-of-pocket expenses since the member is responsible for any difference between HMSA’s eligible charge and the nonparticipating provider’s actual charge. For Health Plan Hawaii, services from a non-network provider are not covered with the exception of emergency care and/or referrals from your in-network personal care physician. For Kaiser Permanente: Please refer to your employer’s applicable Face Sheet, Group Medical and Hospital Service Agreement, Benefit Schedule, and Riders (collectively known as the “Service Agreement”). The Service Agreement is the legal binding document between the Health Plan and its members. In the event of ambiguity, or a conflict between this summary and the Service Agreement, the Service Agreement shall control. HMSA (PPO 460)
HMSA (YI)
PREFERRED PROVIDER PLAN
HEALTH PLAN HAWAII PLUS
GENERAL PROVISIONS
YOUR CHARGE
YOUR CHARGE
YOUR CHARGE
Participating
Nonparticipating
Providers
Providers
Annual Deductible
(Except other services) Maximum $300 per family Annual Copayment Maximum
Lifetime Maximum
Extension Student Coverage
PHYSICIAN SERVICES
PLAN PAYS
PLAN PAYS
PLAN PAYS
Office Visits
Hospital Visits
HOSPITAL SERVICES (Includes Maternity Benefits)
Room & Care -
semiprivate room rate; unlimited number of days Intensive Care Unit, Coronary Care Unit,
Ancillary Services, Inpatient Laboratory and X-ray SURGICAL SERVICES
Surgery (includes Maternity Benefits)
Anesthesiologist
OUTPATIENT LAB & X-RAY SERVICES
X-ray films for injuries (within 48 hours) and
diagnostic services
Radiotherapy for malignancies and non-
malignancies
HMSA (PPO 460)
HMSA (YI)
PREFERRED PROVIDER PLAN
HEALTH PLAN HAWAII PLUS
MENTAL HEALTH SERVICES(1) PLAN PAYS
PLAN PAYS
PLAN PAYS
INPATIENT (1)
Participating
Nonparticipating
INPATIENT (2)
Providers
providers
Hospital & Facility Services -
Psychiatrist & Psychologist Services -
OUTPATIENT (1)
OUTPATIENT (2)
Psychiatrist & Psychologist Services -
(1)The following mental illness conditions are not subject to mental health plan maximums, bipolar mood disorder types I and II, delusional disorder, dissociative disorder, major
depressive disorder, obsessive-compulsive disorder, schizophrenia and schizo-affective disorder. (2)The following mental illness conditions are not subject to mental health plan maximums: schizophrenia, schizo-affective disorder, and bipolar types I and II, delusional disorder,
major depression, obsessive-compulsive disorder, and dissociative order. COMPLEMENTARY CARE COVERAGE
Annual Plan Maximum
Choice of Providers
Inc. and its affiliate Healthyroads, Inc. Requirements
CHIROPRACTIC SERVICES
Complementary and alternative care access Discount Program for HMSA health plan Office visit for neuromusculoskeletal disorders members. Visit our website for more info at www.hmsa.com/myhealth/programs/naturalpathways/ Appliances (e.g. hot/cold packs, braces)
ACCUPUNCTURE SERVICES
HMSA (PPO 460)
HMSA (YI)
PREFERRED PROVIDER PLAN
HEALTH PLAN HAWAII PLUS
OTHER SERVICES
PLAN PAYS
PLAN PAYS
PLAN PAYS
All benefits payable after $100 annual deductible Participating
Nonparticipating
Providers
providers
Air Ambulance
Allergy Testing
Ambulance
Ambulatory Surgical Center
Physician Services: All but $14 per visit Appliances & Equipment
Blood and Blood Products
Chemotherapy
Dialysis and Supplies
Emergency Room Facility
Evaluations for the Use of Hearing Aids
Organ Donor Services
Outpatient Injections
Physical Therapy/
Occupational Therapy (HMSA Only)
Speech Therapy
HMSA (DRUG 374)
HMSA (DRUG 375)
PREFERRED PROVIDER PLAN
HEALTH PLAN HAWAII PLUS
PRESCRIPTION DRUGS
PLAN PAYS
PLAN PAYS
PLAN PAYS
Participating
Nonparticipating
Participating
Nonparticipating
Kaiser Pharmacy
Pharmacy
Pharmacy
Pharmacy
Pharmacy
PREFERRED BRAND
OTHER BRAND NAME
DIABETIC SUPPLIES
SPACERS FOR
INHALED DRUGS
PEAK FLOW METERS
HMSA (DRUG 374)
HMSA (DRUG 375)
PREFERRED PROVIDER PLAN
HEALTH PLAN HAWAII PLUS
PRESCRIPTION DRUGS
PLAN PAYS
PLAN PAYS
PLAN PAYS
(continued)
Participating
Nonparticipating
Participating
Nonparticipating
Kaiser Pharmacy
Pharmacy
Pharmacy
Pharmacy
Pharmacy
CONTRACEPTIVES
50% of applicable charges for Federal Food and contraceptive drugs and devices to prevent contraceptives(3)
contraceptives(3)
contraceptives(3)
contraceptives(3)
50% of applicable charges for Federal Food contraceptive drugs and devices to prevent unwanted pregnancies. No refund is given if 50% of applicable charges for Federal Food contraceptive drugs and devices to prevent $15/quarter per injection(4)
MAIL SERVICE PRESCRIPTION PROGRAM
From an HMSA contracted provider – 90 day supply From an HMSA contracted provider – 90 day supply Members may purchase mail order refills for consecutive day supply upon payment of two does not apply to certain drugs and mailing is limited to addresses inside the state of (3) Preferred oral contraceptives include: Alesse Contraceptives (Wyeth-Ayerst), Desogen and Mircette contraceptives (Organon Pharmaceuticals), Nor-Q-D contraceptives (Watson Labs), and Tri-
Levlen and Yasmin contraceptives (Berlex Laboratories). Note: This list is subject to change.
(4) A Separate copayment may be charged for administration of the injections.
Note: (HMSA Drug Plans 374 and 375)
HMSA contraceptive supplies are not subject to the annual deductible. Copayments will not count towards the annual copayment maximum and benefits paid will not be applied towards the lifetime maximum contra. When a prescribed brand name drug has a generic equivalent that is listed on the Hawaii Drug Formulary of Equivalent Drug Products, you will be responsible for the appropriate copayment plus the difference between the generic and brand name cost. This procedure will apply regardless of whether you chose not to use the generic equivalent or the particular generic equivalent was not available at the pharmacy. Each drug dispensed is limited to a 30-day supply. A 30-day supply is defined as a supply lasting the member for a period consisting of 30 consecutive days. HMSA (VISION AI)
HMSA (VISION CK)
PREFERRED PROVIDER PLAN
HEALTH PLAN HAWAII PLUS
PLAN PAYS
PLAN PAYS
PLAN PAYS
Participating
Nonparticipating
Participating
Nonparticipating
Provider
Provider
Provider
Provider
EYE EXAMINATION
copayment per visit(5)
member copayment(6)
(5) If you belong to a health center that has an ophthalmologist or optometrist, you must receive your vision exam from these providers. If you don’t go to your health
center vision provider for your vision exam, the vision exam will not be a covered benefit and you will be responsible for payment. If your health center does not have an
ophthalmologist or optometrist, you may receive your vision exam from any provider listed under the HMO Vision Network. Your plan does not provide benefits for vision
exams by non-network vision providers. Contact our Customer Service department for a copy of our HMO Vision Network directory.
(6)Frames must be chosen from a group selected by the provider. If the member chooses a frame outside of the group, the member will have to pay any difference
between HMSA's allowance and the provider's charge for the frames. If the member replaces only the lenses of his/her glasses, the allowance for frames cannot be
applied to the cost of the lenses.
Note: (For HMSA Vision Plan AI & Vision Plan CK)
Exclusions: Sunglasses, prescription inserts for diving masks and any protective eyewear, nonprescription industrial safety goggles, nonstandard items for lenses, including
tinting, blending, oversized lenses, invisible bifocals or trifocals, and repair and replacement of frame parts and accessories.
- See next page for Dental Plan Benefits Summary - Dental Comparison Chart – 2007
Hawaii Dental Service
Dependent age limit through age: 18
Dependent full-time student age limit through age: 24
DENTAL BENEFITS
% PLAN COVERS
HIGH OPTION
LOW OPTION
MAXIMUM AMOUNT per calendar year per member
DIAGNOSTIC
• Examinations – twice per calendar year • Bitewing x-rays – twice per calendar year • Other x-rays (full mouth x-rays limited to once every 3 years
PREVENTIVE SERVICES
• Stannous Fluoride (once per calendar year through age 19) • Space Maintainers (for dependent children through age 17) • Sealants (through age 18)- one treatment application, once per lifetime only to permanent posterior molar teeth with no cavities and no occlusal restorations, regardless of the number of surfaces sealed. RESTORATIVE
(white-colored) fillings- limited to the anterior (front) teeth Note: Compsite restorations on posterior (back) teeth will be processed as the alternate benefit of an amalgam-the patient will be responsible for the cost difference up to the Amount Charged by the dentist. • Crowns and gold restorations (once every 5 years when teeth cannot be restored with amalgam or 50% composite fillings) Note: porcelain (white) crowns on posterior (back) teeth will be processed as the alternate benefit of the metallic equivalent- the patient is responsible for the cost difference up to the Amount Charged by the dentist. • Root canal treatment, retreatment, apexification, apicoectomy DENTAL BENEFITS
% PLAN COVERS
HIGH OPTION
LOW OPTION
PERIODONITICS
• Periodontal scaling and root planning (once every two years) • Gingivectomy, flap curettage and osseous surgery (once every three years) • Periodontal maintenance-twice pre calendar year
PROSTHODONTICS (once every 5 years; ages 16 and older)
• Removable Dentures (complete and partial- once every 5 years; ages 16 and older) ORAL SURGERY
• Other oral surgery procedures to supplement medical care plan ADJUNCTIVE GENERAL SERVICES
• Consultations (by Specialists not performing services) • Sedation: General & IV- Oral Surgery only • Palliative (emergency) treatment (for relief of pain but not to cure) ORTHODONTICS
• Maximum amount payable by HDS for an eligible patient shall be $1,000 lifetime per case paid in Orthodontic services are not covered:
*
If services were started prior to the date the patient became eligible under this employer’s plan.
*If a patient’s eligibility ends prior to the completion of the orthodontic treatment, payment will not
continue.
*If your employer elects to remove the orthodontic benefit coverage will end on the last day of the month
that the change occurred.
Shaded areas indicate coverage after a Wait Period of 12 months of continuous enrollment in the plan for new enrollees after January 1, 2007. New Multi-State Coverage-Visiting a Delta Dental Participating Dentist
• When visiting a dentist on the Mainland, let the dentist know that you have an HDS Multi-state plan and present your HDS member Identification card. • If the dentist is a Delta Dental participating dentist, the claim will be submitted directly to HDS for you. • Provide the dentist with the HDS mailing address and toll free number located on the back of your member identification card. • HDS’s payment will be based upon the Delta Dental dentist’s Allowed Amount for his/her state. • Your Patient Share will be the difference between the Delta Dental dentist’s Allowed Amount and HDS’s payment amount.

Source: http://iws.punahou.edu/epunahou/formschannel/hr/Del%20Files/Med&DentalComparisonChart2007.pdf

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